What is EBP? Classic Definition of Evidence Based Medicine (EBM) By Aaron Eakman PTOT 413/513 OT Profession Fall 2009 the explicit, judicious and conscientious use of current best evidence from health care research in making decisions about the health care of individuals and populations. Sackett et al., 2000. EBM Typically refers to the medical field Involves the integration of individual clinical experience with the best available external clinical evidence individual clinical experience refers to the proficiency and judgment that individuals acquire through clinical experience and clinical practice. Sacket et al. (1996) Five Step Process An answerable research question is formulated Efficient literature search is conducted Evidence is critically appraised Application of evidence to health care practice An evaluation to the effects of change on the practice Sacket et al., 2000 Evidence Based Practice (EBP) Conceptually similar to EBM Tends to encompass more aspects of health care and rehabilitation Clinical experience does matter Definitions have expanded to embrace the use of best evidence available in conjunction with client choices (Muir Gray, 1997) A Definition of EBP Placing the client s benefits first, evidence based practitioners adopt a process of lifelong learning that involves continually posing specific questions of direct practical importance to clients, searching objectively and efficiently for the current best evidence relative to each question, and taking appropriate action guided by evidence. Gibbs (2003) Fall 2009 1
Research Knowledge is only one source of information In fact, EBP can be considered to be a combination of information from what we know from research, what we have learned from clinical wisdom, and what we learned from information from the client and their family. This combination of information enables us to work together with clients and families to make the best use of knowledge. An EBP Perspective on Clinical Reasoning Research (literature appraisal) Law et al., (2004) Client Centered (needs and wishes) Clinical Wisdom (tacit knowledge) What else is there? Evidenced based rehabilitation Evidence informed practice Evidence based healthcare Evidence based clinical practice Best practice Ultimately EBP is about your ability to critically examine, evaluate and apply knowledge then assess your findings. Criticisms of EBP it is too time consuming there is not enough evidence the evidence is not good enough readers of clinical research cannot distinguish between high h and low quality studies clinical research does not provide certainty when it is most needed More Criticisms of EBP findings of clinical research cannot be applied to individual patients clinical research does not tell us about patients' true experiences evidence based practice removes responsibility for decision i making from individual id therapists. Herbert et al. (2001) but it s the best model of practice currently available. Reality of EBP Many practitioners take little or no time to review current medical findings Even extremely busy practitioners can initiate evidencebased practice through planning and habit building EBP requires extensive clinical expertise, and is not just cookie-cutter practice EBP emphasizes the best available evidence for each client s situation (Law & MacDermid, 2008) Fall 2009 2
Why worry about EBP? The Accreditation Council for Occupational Therapy Education (2006) has standards which dictate student competence in core aspects of evidence based practice. WHAT DO YOU VALUE? The Process of EBP Identify an issue or area of uncertainty Translate uncertainty into a relevant, answerable question Search for and retrieve the evidence Critically appraise the evidence Apply the results in clinical practice Evaluate, reflect on your performance What s your problem?!? Take a moment think of when you were observing therapists treating clients what were they doing?...why were they doing it?...what outcome were they hoping to achieve? What s your problem?!? Now please write down a clinical problem related to this. Patient: How could you describe a group with a similar problem? How you would describe the patient to a colleague? What are the important t characteristics ti of this patient? Intervention Comparison Outcome Patient Intervention: what you plan to do for that patient. What treatment method or modality will you choose? Comparison Outcome Fall 2009 3
Patient Intervention Comparison: the main alternative you are considering. What specific alternative method or modality are you considering? This one may be optional as in some cases, there may not be an alternative. Outcome Patient Intervention Comparison Outcome: It specifies the result(s) of what you plan to accomplish, improve or affect and should be measurable. ROM, pain, strength, endurance, walking, dressing, homemaking, driving, working, playing, socializing, quality of life, etc. The Clinical ( Answerable ) Question Patient Describe pt In children with cognitive or physical disabilities Intervention Comparison Outcomes Intervention Which main intervention What are the factors that facilitate inclusion in activities Which alternative TX for comparison compared with the barriers What will this affect or accomplish affecting overall participation in activities What s your question? Patient Intervention Comparison Outcome What s your question? What we will do today Use your PICO question to search for evidence ( C may be optional). Identify data bases and generate key words for a search. Locate relevant literature related to your clinical i l (PICO) question. Be prepared to change your question. Report to the class two pieces of evidence relevant to your question. Fall 2009 4
Best Research Evidence Worthy of our attention - PICO worthy? Understandable - To you?!? Valid - credible and current Clinically important meaningful outcome? Applicable to your setting and your clients I II III IV V Evidence Hierarchy Systematic review of multiple well designed randomized controlled trials. Well designed randomized controlled trial. Well designed trials without randomization, single group pre post test, cohort, time series, or case controlled studies. Well designed nonexperimental studies Opinions of respected authorities, or reports of expert committees. Moore et al. (1995) Does evidence from qualitative studies count? Challenging taken for granted practices Illuminating factors that shape client and clinical behavior Developing new interventions ti based on client s experiences Enhancing an understanding of organizational culture and management Popay & Williams (1998). Collecting your own evidence Document your actions / observations systematically (especially with something new) Keep track of all assessment results, review them annually Ask patients/clients to complete a survey upon discharge Listen to patients/clients Where can I find the evidence? Ask a librarian Really! http://www.pedro.fhs.usyd.edu.au http://www.otseeker.com http://www.cochrane.org http://scholar.google.com http://www.guideline.gov http://www.isu.edu/library How can I learn to critically appraise the evidence? Take PTOT 514 Be engaged in class Have a desire to learn Fall 2009 5
CLINICAL EXPERTISE IN PRACTICE Your wisdom and experience is important Listen to your clients Be explicit in providing research information to clients to enable them to make informed decisions Be systematic in your reflections and decision making Develop simple tracking and reporting systems Some critical points about EBP EBP is one clinical decision making model Utilizes both research and clinical expertise The evidence is interpreted and implemented by informed clinicians It will not give you the absolute truth Best practice is ultimately based upon the best external evidence, the patient s perspectives and the practitioners clinical wisdom How can you learn more about EBP? www.herts.ac.uk/lis/subjects/health/ebdm.htm www.cche.net www.otevidence.info www.ebdm.med.aulberta.ca http://www.otseeker.com www.pedro.fhs.usyd.edu.au/index.html Ask a librarian! REALLY!!! (282 3104) References Gibbs, L. (2003). Evidence Based Practice for the Helping Professions: A Practical Guide with Integrated Multimedia, Pacific Grove, CA: Brooks. Herbert et al. (2001). Evidence based practice imperfect but necessary. Physiotherapy Theory and Practice. 17(3); 201 211. Law, M. & MacDermid, J. (2008). Evidenced based rehabilitation. Thorofare, NJ, Slack. McKibbon KA (1998). Evidence based practice. Bulletin of the Medical Library Association 86 (3): 396 401. Mohide A. What is RBP? How do we Facilitate its Use?. Evidence based Practice Conference Proceedings, Marymount Unversity, 2002; 7 13. References Moore, A., McQuay, H., Muir Gray, J. A. (1995). Evidenced based everything. Bandolier. 1(2): 1. Muir Gray, J. A. (1997). Evidenced based health care. London: Churchill Livingstone. Popay, J. & Williams, G. (1998). Qualitative research and evidence based health care. Journal of the Royal Society of Medicine. 91(suppl35): 32 37. Sackett DL, Staus SE, Richardson WS, Rosenburg W, Haynes RB. Evidenced based Medicine: How To Practice and teach EBM. Churchill Livingston. 2000. Sacket et al. (1996). Evidenced based medicine: What it is and what it isn t. British Medical Journal. 312 (7023)71 72. Fall 2009 6